Provider Demographics
NPI:1164908661
Name:RIDGE, KYLE RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:RUSSELL
Last Name:RIDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:983075 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-3075
Mailing Address - Country:US
Mailing Address - Phone:402-595-2275
Mailing Address - Fax:402-595-1970
Practice Address - Street 1:983075 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-3075
Practice Address - Country:US
Practice Address - Phone:402-595-2275
Practice Address - Fax:402-595-1970
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE8233207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine